DSA 1: Atypical Chest Pain, Dysphagia, Odynophagia Flashcards
What are the sxs, dx and tx for pill-induced esophagitis
severe retrosternal chest pain, odynophagia & dysphagia - several hr after taking pill, may occur suddenly and persist for days;
some pt (esp elderly) -little pain, present w/ dyphagia
Dx: Med Hx, endoscopy may reveal one or more discrete ulcers (shallow or deep)
Tx: eliminate offending agent –> heals quickly; drink 4 oz water with pills
What is the definition, etiology and causes of diffuse esophageal spasm
multiple spastic contractions of circular M in the esophagus
- fxnal imbalance btn excitatory & inhibitory post-ganglionic paths
- disrupting the coordinated components of peristalsis - uncoordinated esophageal contraction (long duration & recurrent)
barium swallow shows : corkscrew esophagus (MC) or rosary bead esophagus
causes = 1- idiopathic, 2- due to GERD, emotional stress, diabetes, alcoholism, neuropathy, radiation therapy, ischemia or collagen vascular dz
What is the treatment for PUD?
acid suppression: PPI, H2 blocker PO or IV if acute GI bleed
eradicate H. pylori
stop smoking
discontinue NSAIDs, endoscopic intervention (if active bleed)
surgery for complications
GU ONLY: exclude malignancy- EGD w/ repeat Bx of ulcer
Atypical Chest Pain DDx
MI, aortic dissection, pul embolism (life-threatening)
Esophageal Perforation (life-threatening)
PUD
Nutcracker esophagus
Diffuse esophageal spasm
GERD
Food bolus impaction/obstruction
what is the presentation, diagnostic tests and treatment for esophageal perforation
- distress upon presentation
- pleuritic/retrosternal chest pain;
pneuomediastinum or subQ emphysema (snap, crackle, pop when push on chest)
Dx test: CXR or CT w/ contrast (see air in mediastinum/subQ emphysema)
Tx: stabilize, NPO, paraenteral ABx, surgery, endoscopic stenting
What are the hx and sxs in pts w/ eosiniphilic esophagitis
(compare & contrast adults & children)
Hx: allergies or atrophic conditions (>50% pt) -stimulate inflam; Hx of food bolus impaction, long hx of dysphagia of solid foods
M>F
Both: eosinphilia, dysphagia
adults: pyrosis, poor medication response, regurg undigested food
kids: vomit, difficulty feeding, failure to thrive
how do you Dx and Tx GERD
Dx:
- clinically based on sxs, hx, PE
- consider ambulatory 24-48 hr esophageal pH recording & impendance testing
- CBC, H. Pylori testing
- EGD or ABD imaging if alarming features, > 60 yo, persistent, sxs despite Tx
Tx:
- empiric (if no alarming features) - try acid suppression (PPI –> H2 blocker) & lifestyle modifications
- surgery - (symptomatic hiatal hernia)
- H. pylori eradication if indicated
How do you treat esophageal strictures
dilation at the time of EGD - some require intermittent dilation
long term PPI to decrease reoccurence
endoscopic injection of steriods into refractory strictures
What is the etiology, Dx and Tx for Zenker Diverticulum
(structural oropharyngeal dysphagia)
etiology:
- structural prob: false diverticula involves herniation of mucosa & submucosa thru the M. layer of the esophagus posteriorly btn the cricopharyngeus M & the inferior pharygneal constrictor Ms (at phayngeoesophageal jxn)
- loss of UES elastivity
- occurs in killian’s triangle: natural weakness proximal to the cricopharyngeus
Dx: video esophagography or barium swallow (do these before EGD to prevent perforation!)
Tx: Surgery- upper mytomy or surgical diverticulectomy
how do you prevent pill-induced esophagitis
take pill w/ 4 oz of water & remain upright for 30 mins after
dont give known offending agents to pts w/ esophageal dysmotlity, dysphagia or strictures
what are symptoms that present w/ pul embolism
hypercoag state - recent travel or surgery
sudden onset, pleuritic chest pain, SOB
hypoxia, hemodynapic collapse
increase RR & HR
Wells criteria
Which disorder is a motility disorder, presents with esophageal dysphagia when accompanied by weak peristalisis & stomach acid reflux due to the LES?
GERD
what acute and long term complications of caustic esophageal injury
Acute: perforation (pneumonitis, mediastinitis, peritonitis); bleeding; esophageal-tracheal fistulas
long-term - esophageal stricture (70%) - require recurrent dilations
risk of esophageal SCC 2-3% - endoscopic surveillance 15-20 yrs after ingestion
What are atypical sxs of GERD
which symptoms are alarming enough to perform an endoscopy, obtain dirested radiographic Abd imaging, or surgical evaluation?
atypical: asthma, chronic cough, hoarseness, laryngitis, aspiration pneumonitis, chronic bronhcitis, sleep apnea, dental caries, halitosis and hiccups
Alarming features:
- unexplained wt loss
- persistent vomitting –> dehydration
- constant/severe pain
- dysphagia/odynophagia
- palpable mass/adenopathy
- hematemesis
-
melena
- anemia (Fe deficiency) –> Occult bleeding
describe the difference btn sliding hiatal hernia & paraesophageal hernia
sliding: herniation of stomach into mediastinum thru esophageal hiatus –> bc increase intra-abd pressure from obesity, pregnancy & hereditary (affected pts may have GERD)
paraesophageal hernia: herniation into the mediastinum includes: visceral structure other than gastric cardia & most commonly the colon (can lead to an upside-down stomach, gastric volvulus, strangulation of the stomach) (pictures)
What are risk factors and PE findings for GERD
risk factors:
- increased abd girth/obesity,
- pregnancy,
- hiatal hernia- barium swallow
PE: possibly normal, epigastric pain, dental carries, hoarseness
What are diagnostic characterisitics of achalasia
peripheral blood smear ; trypanosoma cruzi parasite (if chagas)
barium esophagram - bird beak distal esophagus - esophageal dilation, loss of esophageal peristalsis, poor esophageal emptying
EGD- always performed to evaluate distal esophagus & GE jxn to exclude distal stricture or submucosal infiltrating carcinoma; Bx = loss of ganglion cells w/i esophageal myenetric plexus
esophgeal manometry.- confirm Dx - complete absence of normal peristalsis & incomplete LES relaxation w/ swallowing
CXR- air-fluid level in enlarged, fluid filled esophagus
If a white, 55 yo male presents to your office w/ long history of GERD symptoms (heartburn & regurg), what are you concerned about
- Barretts esophagus -doesn’t have specific sxs, most asym & only sxs present related to long term GERD
- Adenocarcinoma: RF = chronic GERD, hiatal hernia, obesity, white, male > 50 yo
PE: nothing specific
What are lifestyle modifications to suggest for pts w/ GERD
decrease alc & caffeine
small low fat meals
incline bed
assess psychosocial
reduce weight
avoid large meals, smoking, alc/caffiene, chocolate, fatty food, citrus juices & NSAIDS
how do you test and treat aortic dissection
test: CXR widened mediastinum
CT w/ contrast = definitive!
Tx: surgery/ BP management
What is Hamman’s sign
PE
auscultation - crunching, rasping sound, synchronous w/ heartbeat
heard over precordium during systole (esp in L lateral decubitus position) - maybe w/ muffled heart sound
(esophageal perforation &/or pneumomediastinum/subQ emphysema => differentiate btn Lung and GI problem by pressence of dyspnea)
how do you diagnose and treat CMV-infectious esophagitis
endoscopy- one or more large, shallow, superficial ulcerations (may be infected in colon and retina too)
Tx: if pt w/ HIV - immune restoration w/ ART
What are characterisitcs of Chagas Dz
esophageal dysfxn that is indistinguishable from idiopathic achalasia;
pts from endemic regions (mexico, central & south america);
by the bite of reduviid (kissing) bug transmits protozon, trypanosoma cruzi;
chronic phase of dz yrs after infxn - results from destruction of autonomic gangion cells throughout the body
how do you test and treat pul embolism
ECG: sinus tach (MC)** or **S1Q3T3
CTA: best but may not for best option of pt (pregnant, renal failure)
VQ scan, LE venous doppler US
Tx: stabilize, anticoag (aspirin unless contraindicated!)
What are the Hx/PE findings for esophageal web & how do you Dx
(strucutal oropharyngeal dysphagia)
dysphagia with solids: if proximal = oropharyngeal (if mid- esophageal)
can be asymp or intermittent & not progressive
if circumferential - looks similar to schatzki ring (but these are distal & webs are mid-proximal)
Dx: barium swallow (esophagram)
What are RF and Complications for Pill-induced esophagitis
RF: medications (NSAIDs, KCl, Alendronate & risedronate (for osteoporosis), iron, ABx)
most likely occur bc swallow pill w/o water or while supine (increased risk in hospitalized/bed-bound pts)
complications: severe esophagitis w/ stricture, hemorrhage, perforation
What is the definition, etiology and association nutcracker esophagus
hypertensive peristalsis
-swallowing contractions are too powerful
greater amplitude & duration but normal coordinated contraction
associated w/ increased freq of depression, anxiety & somatization
what is the atypical presentation of MI
how do you test & treat
dyspepsia
epigastric pain
distressed, diaphoretic, pale
impending doom
murmur
test: ECG, tropnoin CXR
treat: stabilize, aspirin, PCI or CABG
What is the etiology for Achalasia
(motlity esophageal disorder) –> solids & liquids (progressive)
increased incidence w/ age
- propulsion problem - loss of peristalsis (distal 2/3) & failure of deglutitive LES
- denervation of esophagus from loss of NO producing inhibitory neurons (ganglion cells) in the myenteric plexus
what are risk factors for infectious esophagitis?
Immunocompromised pt - increase risk of opportunistic infxn
increased risk for Cadida infxn - uncontrolled diabetes, treated w/ systemic corticosteroids, radiation therapy, systemic Abx
HSV- can affect normal hosts
Presentation & DDx for oropharyngal dysphagia?
difficulty initiating swallowing
food sticks at level of suprasternal noth
possible nasopharyngeal regurgitation or aspiration
solids only (structural cause) OR solids & liquids
What is the etiology & Tx for esophageal webs
(structural oropharyngeal dysphagia)
Etiology:
- stuctural prob –> thin, diaphragm-like membrane of squamous mucosa; proximal or mid esophagus
- congenital
- acquired: eosinophilc esophagitis or rarely Plummer vinson syndrome
Tx:
dilatation (bougie dilator) or small endoscopic electrosurgical incision
long-term PPI if persistent heartburn or need repeat dilations
What are causes of the esophageal perforation (life-threatening chest pain due to GI)
Spontaneous: forceful retching/vomit; Hx of alc use; Boerhaave’s - transmural rupture at G-E jxn
Iatrogenic: trauma, medical cause - NGT placement of endoscopy
What is the presentation of a pt w/ esophageal strictures
(structural esophageal dysphagia)
gradual (mon-years),
progressive: but reflex/heartburn LESSEN/improve bc the stricture act as a barrier to reflux (dysphagia will continue to worsen)
1st solids –> then both
What is the presentation and DDx for esophageal dysphagia
food sticks in the mid-lower sternal area
possible regurg, aspiration or odynophagia
solids only OR solids & liquids
what are similarities for nutcracker esophagus and diffuse esophageal spasm
both = esophageal dysmotility
both symptoms: dysphagia to solid & liquids; atypical chest pain
dysphagia: intermittent, not progressive
Dx: Manometry & EGD to exclude mechanical & inflam leasons (diffuse esophageal spasm - use barium swallow)
Tx: Nitrates, Ca2+ antagonists, treat concomitant mental healthy
what are diagnostics for PUD
EGD w/ Bx (exclude malignancy in GU)
X-ray/CT/MRI if suspect complications (perforation, penetration, obstruction)
CBC (anemia) & Chemistry (UGIB = increased BUN)
Nasogastic lavage - but if neg DOES NOT exlude active bleeding from DU
detecting H.pylori - stop PPI 14 days before fecal and breath test (bc risk of false neg)
- fecal Ag test: sensitive, specific, inexpensive (confirm eradication)
- IgA Ab in serum (not good for confirming eradication bc present for weeks after)
- Urea Breath Test: confirm readication
- Upper endoscopy w/ gastric Bx -warthin-starry’s silver stain and immunohistochemistry stain & histology/rapid urease test of antrum (Clofazimine)
what is globus pharyngeus
sensation of a lump lodges in the throat BUT swallowing unaffected
(unlike dysphagia which is problem w/ swallowing)
What is the presentation for rheumatologic esophageal dysphagia
What is the presentation of a pt w/ achalasia
gradual, progressive** dysphagia w/ solids **& liquids
regurg undigested foods (diff from zenker diverticulum bc it nocturnal regurg)
substernal discomfort/fullness (ma be associated w/ meals, may last several hrs)
adaptive maneuvers = eat slowly, lift neck or through shoulders back to enhance esophageal emptying
wt loss
What is it called when a pt presents angular chelitis, glossitis, koilonychia and weakness/fatgiue
what else will they present with
Plummer Vinson syndrome (MC middle age women)
iron def anemia (weakness & fatigue)
symptomatic proximal esophageal webs
How do you diagnose and treat herpes simplex esophagitis
endoscopy- multiple small, deep ulcers (may see oral ulcers too)
Tx: symptomatically
if immune compromised tx w/ oral acyclovir
what are PE findings of Achalasia
& how do you treat?
PE: idiopathic - nothing specific, see wt. loss & 2ndary - swelling, Romana sign- unilateral painless swelling around eye (periorbital), arryhthmia, fever
Tx:
- reduce LES pressure - nitrates & Ca2+ channel blockers; botox
- pneumatic balloon dilation - risk of perforation/bleeding
- surgery (myotomy) - up to 30% have GERD after; all pts given PPI qd
- w/o Tx - esophagus becomes dilated - sigmoid esophagus
what is due to structural esophgeal dysphagia w/ smooth, circumferential, thin mucosal structures, distal & is associated w hiatal hernias
What is the Hx, Dx, and Tx for this?
=Esophageal ring aka Schatzki ring
Hx: intermittent, NOT progressive dysphagia for solid foods; reflux sxs common; “steakhouse syndrome” = large poorly chewed bolus cause food impaction (pass on own w/ drink, after regurg, if impacted –> extracted via endoscope
Dx: barium swallow
Tx: Dilation (bougie dilator); small endoscopic electro surgical incision; if persistent reflux sxs - long term PPI
Differentiate primary, secondary and pseudo-achalasia
1- idiopathic - loss of ganglion cells w/i the esophageal myentric plexis
2ndary- MC: Chagas dz
other 2ndary causes = lymphoma, Ca, chronic idiopathic intestinal pseudoobstruction, ischemia, neurotropic virus, drugs, toxins, radiatino therapy, postvagotomy
Pseudoachalasia = primary of metastatic tumors invade the GE jxn - resemble achalasia
how do you tx caustic esophageal injury
hospitalize - icu
Nasogastric lavage** & oral antidotes **SHOULD NOT be used bc re-exposure to corrosive agent
inital treatment - supportive - NPO, IVF, IV PPI and analgesics; monitor for signs of deterioation –> emergent surgery; NO corticosteroids or ABx
Laryngoscopy- pts w/ resp distress - access for need of tracheostomy
EGD- w/i 12-24 hrs to assess extent of injury (no injury - psychiatric referral)
severe injury -deep/circumferential ulcers/necrosis (black discoloration) ==> high risk up to 65% of acute complications
What is your DDx for mechanical obstruction esophageal dysphagia
esophageal web (plummer-vinson syndrome)
hiatal hernia
GERD- unresponsive reflux dz w/ esophagitis (pts have dyphagia & odynophagia)
GERD complications: esophageal stricture & barret esophagus
What are typical sxs for GERD
typical:
- 30-60 mins after eating, associated w/ spicy, alc, caffiene
- symptoms upon reclining
- epigastric abd pain/abd fullness
- N/V
- intermittent, not progressive, solid & liquid esophageal dysphagia
- waterbrash- bad taste in mouth
- “heartburn”/indigestion
what is the prevelance, RF, Dx and Tx for esophageal adenocarcinoma
white, male
RF: GERD-BE –> dysplasia –> adenoCa
Dx: EGD w/ Bx (distal 1/3) - see squamous to columnar
Tx: endoscopic therapy (ablation)
if a pt presents with rheumatologic oropharyngal dysphagia, what syndrome do you think of??
explain etiology, Hx, PE, Dx, Tx, Complications
what are complications of PUD
bleeding, obstruction (from edema), perforation, penetration into pancreas –> pancreatitis
ulcer along posterior wall of duodenum or stomach –> could perforate into contiguous structures (pancreas, liver, biliary tree)
What complications may occur with GERD
laryngopharyngeal reflux (LPR)- asthma like sxs, acid reflux into larynx, chronic cough & hoarseness
esophagitis
stricture
Barrett’s esophagus –> adenocarcinoma
besides GERD, what is the cause of esophagitis due to refractory reflux
gastrinoma w/ gastic acid hypersecretion (zollinger ellison syndome)
pill-induced esophagitis
resistance to PPI
medical non-compliance
what are RF and sxs of caustic esophageal injury
how do you diagnosis this?
ingestion fo liquid/crystalline alkali or acid
RF = kid - accidental or suicidal- deliberate
almost immediately - severe burn & varying degress of chest pain, gagging, dysphagia & drooling (also see dyspnea, hematemesis, oropharyngeal lesions)
aspiration in stridor & wheezing
Dx: inital exam - circulatory status & airway patency and oropharyngeal mucosa, includig laryngoscopy
chest & abd radiogrphy- look for pneumonitis or free perforation
what is the Tx and complications of eosinophilic esophagitis
tx: PPI, swallow inhaled glucocorticoids, allergist referral, eliminate common food allergy,
esophageal dilation effective in relieving dysphagia in pts w/ fibrostenosis - risk of deep, esophegeal mural laceration or perforation
complications: esophageal stricture, narrow-caliber esophagus, food impaction, esophageal perforation
What are symptoms of food bolus impaction/obstruction
hypersalivation: inability to swallow liquids (including saliva) ==> drooling, frothing/foaming at the mouth
severe chest pain/pressure
dysphagia/odynophagia
sensation of choking
neck/throat pain
retching & emesis
what are the Dx processes used to test
oropharyngeal dysphagia vs esophageal dysphagia
oropharyngeal: video-flouroscopy of swallowing
esophageal:
- mechanical cause: barium swallow or esophageogastroscopy w/ Bx
- motor cause: barium swallow or esophageal motlity study (manometry)
What is the etiology, PE and Dx for esophageal strictures
(structural esophageal dysphagia)
etiology: MC structural prob at GE jxn; presents in 5% of ppl w/ esophagitis
MCC: Peptic secondary to GERD but can also occur btn of eosinophilic esophagtitis
PE: nothing specific
Dx: EGD w/ Bx mandatory in all cases to differentiate peptic stricture from stricture by esophageal carcinoma! ; Barium swallow (maybe useful)
what are the types of esophagitis
& when do you add it to your DDx
esophageal dysphagia & odynophagia (add to DDx w/ this symp)
mainly w/ solids
types:
- pill
- infectious
- eosinophilic
- caustic
what is the management and Tx recommended for Barrets esophagus (BE)
management: surveillance endoscopy - every 3-5 yr for pts w/ BE or high risk of adenocarcinoma (long term, qd or bid PPI may reduce risk of cancer)
Tx:
- PPI- long term, qd/bid to control reflux symptoms - *DO NOT cause regression of BE*
- endoscopic ablation: in pts w/ high grade dysplasia or intramucosal adenocarcinoma (DO NOT surgically resect in pt w/ Ca)
- surgery resection (esophagectomy –> high morbidity/mortality) = NOT recommended
what are risk factors and ways to manage food bolus impaction/obstruction
RF:
- schatzki ring,
- peptic stricture,
- webs,
- esophagitis,
- achalasia,
- CA
management: pass spontaneously, endoscopically, surgery
What is diagnostic for eosinophilic esophagitis
EGD - loss of vascular markings (edema)
longitudinally oriented furrows & punctate exudate
multiple circular esophageal rings creating a corrugated appearance -“feline esophagus” or “tracheal esophagus”
Bx: squamous epithelial eosinophil-predom inflam (15-20 eosinophil per high power field)
What is the most common type of esophageal Ca in the world?
population, RF, sxs, Dx, Tx?
SCC of Esophagus
African american, male, >50 yo
RF: heavy smoker/alc use (synergistic); esophageal disorders (achalasia, HPV, plummer vinson, tylosis); caustic chemical/termal injury (lye ingestion, hot drinks, radiation 5-10 yrs ago)
Sxs: Progressive dysphagia; wt. loss; anorexia, bleeding, hoarseness, cough
Dx: EGD w/ Bx- esp check middle 1/3 (50%)
Tx: surgery (esophagetcomy)
What are life-threatening causes for atypical chest pain that are NOT-GI related
MI
aortic dissection
pul embolism
How do you diagnose and treat candidal esophagitis
endoscopy - diffuse, linear, yellow-white plaques afherent to mucosa
Tx: systemic (fluconazole)
what are risk factors for atypical MI presentation
elderly
female
DM
What is the etiology for PUD
aggressive factors overwhelm defensive factors involved in mucosal resistance & from effects of H. pylori
MC: duodenal bulb (DU) & stomach (GU)
DU- 30-55 yo
GU- 55-70 yo
what is the atypical presentation for aortic dissection
sudden onset- tearing/ripping chest pain
may radiate to neck
syncope, altered mental status
CVA sxs: hemiparesis, extremity parethesia
impending doom
high/low BP
asymmetrical pulse
What are important Hx/PE findings for PUD
Sxs w/ periodicity (several weeks w/ intervals of mon-yrs are pain-free)
- epigastic pain - gnawing, dull, aching or hunger-like
- atypical chest pain
- GIB: coffee ground emesis, hematemesis, melena, hematochezia
exacerbating factors: anxiety/stress, coffee, alc (w/o cirrhosis)
PE: normal in uncompleted PUD; mild, localized epigastric tenderness to deep palpation, hyperactive bowel sounds
What is the etiology and Dx of Barretts esophagus?
etiology:
- specialized intestinal (metaplastic) columnar metaplasia- replaces the normal sqamous mucosa of distal esophagus
- proximal displacement of squamocolumnar jxn
- –> esophageal adenocarcinoma
- RF: complication of GERD or truncal obesity
- Greatest risk : obese, white, male, >50 yo who smokes
Dx: screening EGD considered case by case, esp for ppl with RFs
EGD w/ Bx: orange gastric type epithelium extends up from stomach to distal 1/3 esophagus in tongue-like or circumferential fashion ; Bx = goblet & columnar cells
what is the Hx & PE findings of Zenker Diverticulum
(structural oropharyngeal dysphagia)
-affect upper esophagus w/ vague sxs at first (cough or throat discomfort)
As diverticulum enlarges it retains food (progressive) –> halitosis, spontaneou regrug, nocturnal choking, gurgling in the throat, protrusion in the neck
voice change, wt loss, aspiration –> pneumonia/lung absess
gradual/insidious
MC: older males
